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BOARD OF TRUSTEES SAN JOAOUIN LOCAL HEALTH Dl TRICT <br />Al Crow, Pres. 1 <br />Earl Plmentel, Vine Pres, 601 East Hazelton Avenue <br />Tommy Joyce, Sec'y. Stockton, California 95205 <br />James F. Culbertson <br />John D. Mast, M.D. JOGI KHANNA, M.D., M.R.H., DISTRICT HEALTH OFFICER <br />Virginia Mathews <br />Thomas Schubert, D.V.M. <br />Daphne Shaw <br />Harvey Williams, Ph.D. <br />APPLICATION FOR PERMIT TO CLOSE <br />UNDERGROUN6TrTMMORA ANKS STORING RAZARMUS _MATERIALS <br />GENERAL INSTRUCI'I ONS : <br />❑ 1. Submit all information in triplicate. USE CARBONS. <br />[91'2. Include a detailed site map showing hank location and type, <br />pipin , streets and adjacent properties (north toward the <br />top o the page) location of nearby septic tanks, <br />leachfields, buildings and underground public utility lines <br />(including water, sanitary sewer and storm sewer). <br />Ly 3, Compplete form "APPLICATIal FOR PERMIT FOR UNDERGROUND TANK <br />CLOSURE" . <br />l 4. Complete the "Authorization to Release Analytical Data" form. <br />5. Submit the appropriate fees and complete the "Underground <br />/ Tank Program Fee Worksheet". <br />L�' 6. Procedures should ex lain decontamination techniques if <br />applicable, materials) utilized for rinsate, transportation <br />and/or storage of hazardous waste generated on site, and <br />specify the responsible party(ies) who will be disposing of <br />waste generated on site. <br />7. Procedures should explain purging and/or inerting method. <br />Describe in detail horn soil and/or water samples beneath the <br />tank's invert will be obtained. Refer to "Sampling Protocol <br />for Routine Tank Removais" for sampling criteria. <br />Colete the San Joaquin Local Health District's (SJLHD) <br />"Undmperground Tank Disposition Tracking Record". The holder <br />of the permit shall. be res onsible for ensuring that this form <br />is completed and returned he SJLHD. <br />The maximum review time for Closure Plans is 15 working days <br />from the date of receipt of the adequately completed Plan. <br />EH 23 040 <br />REVISED 12/88 <br />Administration <br />468-3400 <br />Air Pollution <br />468-3470 <br />Clinical Services <br />468-3630 <br />Community Services <br />468-3820 <br />Environmental Health <br />468-3420 <br />AIDS Informalion 468-3820 <br />L"oratory <br />468-3460 <br />SERVING <br />San Joaquin County <br />City of Manteca <br />City of Escalon <br />City of 1-06 <br />City of Tracy <br />City of Ripon <br />San Joaquin County <br />City of Stockton <br />San Joaquin County <br />Public Health Nursing <br />468-3860 <br />WIC <br />468-3283 <br />